Barriers of IUD Acceptance: An Appraisal Through Qualitative Research from West Bengal
Address for correspondence: The Editor/ Managing Editor, Journal of Comprehensive Health Dept of Community medicine NRS Medical College, 138, AJC Bose Road, Kolkata-700014
Intra-uterine contraceptive device is one of the most commonly used reversible method of contraception worldwide. In West Bengal Cu-T acceptance is decreasing in majority of the districts.
To determine the underlying factors for low acceptance of IUCD.
A qualitative study was carried out in Paschim Mednipur and Howrah districts of West Bengal in 2009 by organising seven Focus Group Discussions (FGD) in each district. Three FGDs among beneficiaries’ i. e eligible couples, 3 FGDs among service providers and one FGD among health administrators were undertaken in each district.
Beneficiaries experienced complications like bleeding, pain, misplacement etc. Fear of weakness, white discharge, occurrence of cancer existed. Providers highlighted lack of privacy, need for Cu-T re-orientation training, shortage of IEC material and inadequate time spent by doctor for motivation, rumour among clients. Administrators opined that sustenance of Behaviour Change Communication, training of ANMs would be useful.
Different rumours& myth in the society responsible for low acceptance of Cu-T may be removed through strengthening the Behaviour Change Communication involving Doctors also
In India family planning programme was started in the year 1952, the first country in the world to do so1. Population of India has crossed one billion in 2000 and is projected to reach1.53 billion by 2050 making it the most populous country in the world.2
The current approach in family planning emphasizes on offering high quality contraceptive services among eligible couples on a voluntary basis.2 In India due to emphasis on sterilisation, spacing methods have not been actively promoted nor are they easily available to those who are willing to adopt them3. In spite of many advantages of the IUD as a method of family planning it generally suffers from unpopularity worldwide, with the exception of some countries like China, Egypt, Mexico and Turkey.4
The scenario in India is the same with less than 2% of currently married women adopting the IUD as a method of Contraception4. According to National Family Health Survey-3, the contraceptive prevalence rate is 56.3%, which was varied widely among different states1. But yet the acceptance of Cu-T continues to remain below 2% out of total couple protection rate of 48.5% for the use of any modern contraceptive method (NFHS-3) in India. The Govt of India has introduced Cu-T 380 A in 2002 with effective protection for 10 years replacing the earlier Cu-T 200B, as a part of its Commitment towards provision of quality spacing services in family planning. Only 1.8% of married women of reproductive age group used to practice IUCDs despite the fact that the Government of India offers IUCD services free of cost, it still remains underutilized.2 The contraceptive prevalence rate by any method in West Bengal among currently married women aged 15-49 yrs is 71% and couple protection rate by modern method is 50% .However only 1% married women of reproductive age group currently adopted IUCD in West Bengal (NFHS-3). Knowledge about IUCD has declined from NFHS-2 of 73%to 68% in NFHS-3 in West Bengal5.
Socio-cultural & behavioural factors influence the decision for selection as well as practice of contraceptive method, continuation of use of contraceptive methods and reasons for discontinuation also. In India, a through review of birth spacing methods, especially the IUCD, is needed since the earlier surveys indicated a high rate of discontinuation6. With these above perspective, the present community based qualitative study was carried out with the aim to determine the relevant factors for low acceptance of IUCD in the State of West Bengal.
A Qualitative study was carried out in two districts of West Bengal namely Paschim Midnapur & Howrah during April to September 2009. Out of total 29 blocks in Paschim Midnapur, 3 blocks (Chandrakona-II, Keshpur, and Nayagram) and in urban agglomerates two municipalities (Khargapur & Midnapur town) were selected randomly. In Howrah district, Out of 14 Blocks, 3 Blocks (Domjur, Sankrail and Bagnan) and two Municipalities (Uluberia & Howrah town) were chosen randomly. One sub-centre selected randomly per block so total three sub-centres were selected for study purpose in one district
Focus group discussion:
Seven FGDs were carried out per district: 3 FGDs at different selected sub-centre for beneficiaries, 3 FGDs at BPHC/Rural Hospital among service providers and 1 FGD at district Head quarters level for the Administrators. So, total 14 Focus Group Discussions were held in two districts for qualitative assessment for barriers of IUD acceptance in the community.
On a Prefixed date & time, one Focus Group Discussion was held at each of the selected Subcentres with 10-12 currently married women representatives who were selected by local health workers maintaining homogencity. The aim was to explore the knowledge about Cu-T, experience about it and reasons of non-use. Predetermined topics were discussed one after another within stipulated time with active participation of participants.
Three focus group discussions were conducted among service providers, i.e. ANMs/health workers in each district regarding various aspects of Cu-T, mainly on underlying factors for low use of Cu-T. Two FGDs for rural areas and one for urban were held in Block Primary health centre/Rural Hospital and Municipality health office respectively on pre-fixed date and time with 8-10 health providers.
One Focus Group Discussion was held at district head quarter also. In two districts all district officials (CMOH, Deputy-I, Deputy-II, Deputy III, DMCHO, ACMOH, DPHNO, and BMOH) were interviewed regarding their opinion about low use of Cu-T and suggested methods to overcome the problem were noted. At the end of meeting, main issues brought up during discussion were summarized and reports were prepared.
Report was prepared after summation of all views of the respondents of different categories.
Focus group discussion with beneficiaries elicited that some of them heard about Cu-T, it is a onetime method and may be kept for 10 years. During the discussion session lots of interactions were there, the participants expressed their views clearly, finally all views & opinion about knowledge and practice of Cu-T summarised as follows:
Many of them feared about pain and bleeding, difficulties faced by husband, though there was a very few cases of pain, bleeding among those who adopted Cu-T.
Some of them not aware about Cu-T at all.
One of the mother having two children weared it for 4 years, Cu-T has been removed due to desire to have child, ligation was done in her case after birth of a daughter
Most of them are not motivated due to deep rooted fear in mind about Cu-T that it may cause ulcer of jarau, cancer.
It was revealed that mother-in-law was against it though beneficiaries were willing to adopt Cu-T.
According to them, persistence of fear existed that Cu-T may go inside the abdomen.
FGDs among Providers revealed the following facts::
Inadequate infrastructure: Shortage of space, Lack of Privacy
Lack of Training, IEC Material
Rumours among beneficiaries regarding complications, like Cu-T may go inside (peter vitare dhuke jaoa) and cancer (pare cancer hote pare)
Focus group discussion held at district level & key-informants’ interview reflected the following views:
Training &retraining of all ANMs / Providers are essential.
Complications like perforation of uterus should be referred in time & to appropriate place for management of the patient.
Money from client may bring confidence for acceptance of Cu-T, also generate faith among beneficiaries.
If health Personnel herself (ANM, GNM, Lady Doctor) wear IUD, it might create faith among clients.
Mass media advocacy and Behaviour change communication may improve the situation.
Experience of workers about IUD in the localities as revealed during FGD is reflected form the following case studies- Case study-1: Shyamali 30 yrs old weared Cu-T for more than 4 years.After three & half years some pain feeling was there and she desired removal of it for 2nd issue. But a rumour about Cu-T among neighbours dessiminated that ulceration of jarau (uterus) occurred. As a result local community behaviour changed. There was no interest of Cu-T found among the eligible couples of that particular locality. Shymali in the mean time again adopted Cu-T 380A after birth of 2nd issue, now she is satisfied Cu-T without any complaint.
Case study-2: Kamala 28yrs old desired to remove Cu-T, after removal she became pregnant; she went to local quack for abortion. After some days she died due to sepsis. But a rumour spread through some villages that death was due to wearing of Cu-T, making the community resistance against IUCD as an ideal contraceptive.
The qualitative assessment by FGD about low acceptance of Cu-T by eligible couples established the following facts.
Fear about side effects like ulcer in Jarau, displacement of IUD in other places.
Husband & Mother-in-laws were decision makers and against the use of IUD.
Pain & bleeding experienced by few beneficiaries.
Lack of Privacy in health infrastructure
False Rumour like death, cancer, misplacement still persisting in the Community.
Incentive for acceptors and motivators should also be considered
Rumours in the society responsible for low acceptance of IUCD should be given top priority to remove it.
Successful adopters of IUCD should be acted as Counsellor.
Doctors/ Physicians can be better motivators than health workers.
Display of IEC material at prominent place especially entry point of all health facilities should be ensured.
Mass-media advocacy &Inter- personnel Communication needed to modify behaviour of the community about non-acceptance of IUD.
We gratefully acknowledge the financial support & cooperation made by the Department of Health & Family Welfare, Government of West Bengal for this research work.
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